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Abstract: Background and Aim: Although propofol has been widely used for sedation during esophagogastroduodenoscopy (EGD), adverse events including hypoxia and hypotension may be a concern in the propofol‐based sedation. We aimed to analyze whether administration of midazolam would improve safety and efficacy of propofol‐based sedation in EGD. Methods: One hundred twenty patients who were scheduled to undergo diagnostic EGD were randomly assigned to either midazolam plus propofol (MP) or propofol alone groups. In the MP group, 2 mg of midazolam and 10 mg of propofol were given initially. In the propofol alone group, 40–60 mg of propofol was given initially. In both groups, 20 mg of propofol was given repeatedly to maintain moderate sedation as needed. Vital signs including oxygen saturation were monitored every 2 min. After the patients fully recovered, satisfaction score was investigated from endoscopists, nurses, and patients, respectively. Results: The baseline characteristics did not differ between the MP and propofol alone groups. The mean required doses of propofol was (mean ± standard deviation) 0.3 ± 0.3 and 0.8 ± 0.2 mg/kg in the MP and propofol alone groups, respectively (P < 0.001). In addition, sedation‐related adverse events and recovery time did not differ between the two groups. The proportion of satisfactory did not differ between the two groups (MP vs propofol alone; proportion; patient, 95.0% vs 93.3%, P > 0.999; endoscopist, 73.3% vs 80.0%, P = 0.064; nurse, 73.3% vs 76.7%, P = 0.551). Conclusion: Adding midazolam to propofol did not reduced the safety and efficacy, and sedation using propofol alone could be suitable for sedation during diagnostic EGD. [ABSTRACT FROM AUTHOR]

Abstract: Background and Aim: Same‐day bidirectional endoscopy (BDE) is a commonly performed procedure, but the optimal sequence for the procedure with moderate conscious sedation is not well established. This study investigated the optimal sequence for same‐day BDE under moderate conscious sedation and carbon dioxide insufflation in terms of sedation doses, patient discomfort, and colonoscopy performance. Methods: A prospective randomized controlled study of 120 patients who were scheduled for BDE examination was performed. Colonoscopy followed by esophagogastroduodenoscopy (EGD) examination was performed in 60 patients (colonoscopy‐EGD group), and EGD followed by colonoscopy examination was performed in another 60 patients (EGD‐colonoscopy group). Endoscopists and patients completed a questionnaire to assess objective and subjective discomfort. Results: Baseline demographics, procedure indications, bowel preparation quality, cecal intubation rate/time, colonoscopy withdrawal time, endoscopic interventions, BDE procedure time, colon polyp/adenoma detection rates, patient discomfort, and adverse events were similar between the two study groups. The total doses of fentanyl and midazolam were significantly higher for the colonoscopy‐EGD group than for the EGD‐colonoscopy group (83.4 ± 17.7 vs 68.7 ± 18.6 μg and 6.3 ± 1.4 vs 5.2 ± 1.3 mg, P < 0.0001 and P < 0.0001, respectively). The recovery time to discharge was significantly longer for the colonoscopy‐EGD group than for the EGD‐colonoscopy group (43.5 ± 16.2 vs 34.5 ± 8.9 min, P = 0.0003). Conclusions: Esophagogastroduodenoscopy followed by colonoscopy is the optimal sequence for same‐day BDE under moderate conscious sedation and carbon dioxide insufflation. Following this order allows for a reduction of sedation doses and for shorter recovery times. [ABSTRACT FROM AUTHOR]

Achalasia is a primary esophageal motility disorder. It is the absence of peristalsis in the esophageal body and inability of the lower esophageal sphincter to relax, which characterizes this rare condition. Its features typically include dysphagia, regurgitation, chest pain, and weight loss. The ultimate goal in treating achalasia is to relieve the patient's symptoms, improve esophageal emptying, and prevent further dilatation of the esophagus. Current treatment modalities targeted at achalasia include pharmacological therapy, endoscopic therapy, and surgery. This review focuses on the current therapeutic options and explores the role of peroral endoscopic myotomy in the management armamentarium. [ABSTRACT FROM AUTHOR]

Background and Aim This study was conducted to determine the clinicopathologic factors affecting the stage of ulcerative early gastric cancer ( EGC), focusing on the relationships between cancer stage and degree of endoscopic ulcer depth and morphologic changes. Methods Medical records of 183 cases of ulcerative EGC who had received endoscopic examination two or more times with a minimum interval of one week, and who underwent either curative surgery or endoscopic treatment were retrospectively reviewed. Results Change in ulcer morphology at follow-up endoscopy was observed in 84 cases (45.9%) with improvement and exacerbation of ulcer in 65 (35.5%) and 19 (13.8%) cases, respectively. The presence of type III ulcer ( P < 0.01), and endoscopic findings suggesting submucosal cancer invasion (tumorous bank, fusion of converging folds, hardness or decreased flexibility) ( P < 0.01), and incomplete ulcer healing ( P = 0.036) were independently associated with a higher incidence of submucosal cancer invasion. The incidence of lymph node metastasis was 14.1%, and undifferentiated histology and presence of lymphovascular invasion were significantly associated with a higher incidence of lymph node metastasis ( P = 0.018 and P = 0.005, respectively). Conclusions Endoscopic resection with curative intent may be an acceptable option for EGC combined with endoscopic ulcer or ulcer scar, but should be restricted to cases showing significant improvement in the size and depth of ulcer at follow-up endoscopy, and which are not accompanied with deep ulcer more than the thickness of adjacent mucosal surface and prominent surrounding mucosal fold change. In addition, histologic criteria should meet the conditions of differentiated intramucosal cancer without lymphovascular invasion. [ABSTRACT FROM AUTHOR]

Background and Aim: Adequate mucosal elevation by submucosal injection is important for definitive en bloc resection and prevention of perforation during endoscopic mucosal resection (EMR). The objective of this study is to determine the efficacy of 0.13% hyaluronic acid (HA) solution for high and sustained mucosal elevation during colorectal EMR. Methods: The study was a prospective randomized controlled trial; a total of 196 patients with colon polyps of < 20 mm diameter were enrolled and randomized in a 1:1 ratio to undergo EMR using either 0.13% HA or normal saline (NS). The primary outcome of the study was histopathologically confirmed complete resection. The secondary outcomes such as maintenance of high mucosal elevation and development of complications were also evaluated. Moreover, the relationship between complete resection and the experience of the endoscopist (veteran vs less experienced) was analyzed. Results: Compete resection was achieved in 74 of 93 polyps (79.5%) in the 0.13% HA group and 63 of 96 polyps (65.6%) in the NS group ( P < 0.05). High mucosal elevation was maintained in 83.9% of procedures in the 0.13% HA group and 54.1% in the NS group ( P < 0.01). The frequency of complete resection achieved by less-experienced endoscopists was higher in the 0.13% HA group (79.3%) than in the NS group (62.1%; P < 0.05). Conclusions: Endoscopic mucosal resection using 0.13% HA to colon polyps of less than 20 mm diameter is more effective than NS for complete resection and maintenance of mucosal elevation. [ABSTRACT FROM AUTHOR]

Endoscopic submucosal dissection (ESD) is an alternative to transanal resection (TAR) in treating rectal adenomas, intramucosal cancers, and superficial submucosal cancers. The purpose of this study is to compare the clinical efficacy between ESD and TAR for non-invasive rectal tumors. Between January 1998 and December 2006, 85 patients with preoperative diagnosis of non-invasive rectal tumors were treated by ESD or TAR. En-bloc resection, local recurrence, complication, procedure time, and hospital stay were evaluated retrospectively using a prospectively-completed database. Mean resection sizes were 40 mm and 39 mm in diameter for the ESD and TAR groups, respectively. En-bloc resections with a negative resection margin were achieved in 67% (35/52) of the ESD group, which was significantly higher than the 42% (14/33) in the TAR group. Sixty-three lesions were diagnosed as curative resection, histopathologically. There was no local recurrence in the ESD group, but five local recurrences developed in the TAR group. Two rectal perforations, one minor delayed bleeding, and one subcutaneous emphysema in the ESD group were successfully managed conservatively. There were one minor delayed bleeding and two anesthesia-related complications in the TAR group. The ESD group had a shorter hospital stay than the TAR group (4.9 days vs 7 days), but a longer procedure time (131 min vs 63 min). ESD was more effective than TAR in treating non-invasive rectal tumors, with a lower recurrence rate and shorter hospital stay. [ABSTRACT FROM AUTHOR]

Background and Aim: The aim of the present study was to investigate the clinical effectiveness, safety, and outcome associated with the use of covered expandable Nitinol stents (Taewoong Medical, Seoul, Korea) for the treatment of malignant gastroduodenal obstructions. Methods: Between March 2001 and October 2004, covered expandable Nitinol stents were placed in 68 consecutive patients under endoscopic and fluoroscopic guidance for the following reasons: gastric carcinoma ( n = 49), recurrent carcinoma after partial gastrectomy ( n = 7), or another malignant neoplasm involving the duodenum ( n = 12). Results: Technical success was achieved in 60 of the 68 patients (88.2%). After stent placement, mean dysphagia score improved from a mean of 3.5 to 1.2 ( P < 0.001). The mean period of primary stent patency was 107.2 days. During follow up (mean 4.4 months; range, 1–15 months), major complications (migration [6], bleeding [3], perforation [1], ingrowth [1], overgrowth [7], fistula [1]) occurred in 19 patients (27.9%), and stent migration occurred in six (8.8%) (proximal migration into the stomach [ n = 3], or distal migration [ n = 3]). Recurrent dysphagia (mainly due to tumor ingrowth/overgrowth) occurred in eight patients (11.8%). Conclusion: Covered expandable Nitinol stents appear to offer an effective and feasible palliative therapy in patients with a malignant gastroduodenal obstruction. [ABSTRACT FROM AUTHOR]

Background and Aim: Bleeding from esophageal varices is one of the frequent severe complications arising in patients with liver cirrhosis. The management of esophageal varices is therefore important for patient survival. The purpose of this study was to clarify the predictive factors for mortality in patients with Child C cirrhosis presenting with variceal bleeding. Methods: A retrospective analysis of 77 Child C cirrhotic patients with bleeding from esophageal varices was conducted. All patients received endoscopic therapy. Twenty-nine patients received endoscopic variceal ligation, and 48 patients received endoscopic injection sclerotherapy or endoscopic injection sclerotherapy with ligation. Univariate and multivariate analyses of clinical data were performed to identify the prognostic factors for survival for these 77 patients. Results: Fifty-seven of 77 patients received endoscopic therapy within 24 h after variceal bleeding, and bleeding was controlled in 55 (96.5%). The remaining 20 patients received endoscopic therapy more than 24 h after bleeding. Higher bilirubin level and rebleeding were the predictive parameters for 6-week survival in the 77 patients, according to univariate and multivariate analysis. Higher bilirubin level, refractory ascites, and the presence of hepatocellular carcinoma were the predictive parameters for mortality in 77 patients as determined by multivariate analysis. Conclusions: Endoscopic therapy was effective in controlling acute variceal bleeding of Child C cirrhotic patients. The prognosis of Child C stage patients presenting with variceal bleeding depended on the severity of liver damage and the presence of hepatocellular carcinoma. [ABSTRACT FROM AUTHOR]

Bilateral endoscopic drainage is difficult in malignant hilar biliary obstruction. Recently, unilateral drainage in malignant hilar biliary obstruction has been shown to be equally effective. However, contrast injection leads to cholangitis. There have been no reported studies on contrast-free metal stenting in malignant hilar biliary obstruction. The present study was undertaken to evaluate the results of contrast-free unilateral metal stenting in type II malignant hilar biliary obstruction. We prospectively studied the results of unilateral metal stenting in type II malignant hilar biliary obstruction without contrast injection in 18 patients. A successful endoscopic drainage was achieved in 100% (18/18) of patients with hilar strictures. Cholangitis and 30-day mortality occurred in none. Unilateral endoscopic metal stenting without contrast in type II malignant hilar biliary obstruction is a safe and effective method of palliation. [ABSTRACT FROM AUTHOR]

The authors reflect on the intestinal tuberculosis (ITB), an extra-pulmonary TB that can affect any part of the gastrointestinal track. They relate on the article by Y. Lv and coleagues "LMP2/LMP7 gene variant: A risk factor for intestinal Mycobacterium tuberculosis infection in the Chinese population." They state that endoscopic biopsy and histological examination are required to support a diagnosis for ITB. They mention the role by CD4+ T cells in the control of mycobacterium TB.